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The Global Burden of Disease study is an attempt to quantify the level of morbidity and mortality in the world associated with different disease conditions.  The survey, which has been conducted periodically since the early 1990s, has radically transformed the way in which we think about the health of the world by giving us the DALY – an internally consistent way of measuring and comparing what makes us ill in the world.

A key assumption behind the Global Burden of Disease project is that it is possible to come up with a “Disability Weight” for each health state.  Diseases conditions that are considered worse than other carry higher disability weights than others.  A very important issue in the development of such weights is the question of who should define these conditions?  Should those who have the conditions be the best judge or are they biased?  Should healthy people who have never experienced these conditions be the judge?  Should doctors decide?  Should policy makers?  Should health economists (gasp!!)?

In the past, the GBD has relied upon “expert opinion” to make such decisions.  Well, it seems for the next update of the GBD, which is currently underway, you can also be an expert.  I came across a link to the following survey earlier today that allows you to have some input in these weights.

Here is an example of a question that I was asked:

The first person has swelling and tenderness in the testicles and pain during urination. The second person has lost part of both legs, leaving pain, tingling, and frequent sores in the stumps. The person has great difficulty moving around and has episodes of depression, anxiety and flashbacks to the injury.

Although I don’t have testicles (and despite the fact that most men seem to make it seem like pain there is about the worse possible thing in the world) nor do I have any idea what it must be like to have lost part of both of my legs, I still went with the sores on the stumps as being less healthy.  Would you agree?

I have not had this much geeky fun in ages….

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A new study published today in the New England Journal of Medicine provides convincing evidence of the value of initiating antiretroviral therapy sooner rather than later — even in resource constrained environments.

Until recently, the WHO recommended not initiating treatment until CD4 cell counts fall below 200 per cubic millimeter or when clinical acquired immunodeficiency syndrome (AIDS) developed.  The basic logic behind this treatment strategy is that given that resources are limited, allocate resources to the sickest patients first.

However, over the past few years accumulating evidence from observational studies has suggested that patients who initiate treatment prior to become very sick appeared to have better survival.  While suggestive enough to lead the WHO to release new treatment guidelines last year, the evidence was still just suggestive as it could easily have been that unobserved difference among patients or providers could be driving the results.

The new study was a randomized clinical trial conducted in Haiti.  Both the treatment and control arms had similar baseline levels of CD4 counts and roughly half were randomized to receive early treatment rather than waiting for their CD4 cell levels to fall below 200.  The improvement in mortality was substantial: at 36 months after initiation into the study 98% of the participants in the early-treatment group and 93% in the standard-treatment group were still alive.

This may not sound like a lot as presented here but it translates into about a 75% reduction in the death rate and say we believed that roughly 5 million people have initiated treatment in the developing world, and assuming we can extrapolate the Haiti data to the rest of the world (a big assumption) it could lead to a savings of about 250,000 lives after 3 years and presumably more over time.

The other major finding of the study is that they also looked at the impact of early HIV treatment on tuberculosis related outcomes.  There were half as many cases of tuberculosis in the early initiated group – again a very big effect.

So while these findings really just reaffirm what many have believed for some time, it does now provide convincing evidence that treatment guides should be to treat sooner than later if minimizing mortality is a goal.  This will of course have implications in terms of how limited resources are allocated to treatment  in the developing world.  Since more people now meet clinical guidelines and it will cost more to treat people does that mean who gets priority should be re-evaluated?

Given that there is unlikely to be as large of an increase in funding for HIV programs in the developing world in the coming years, it raises the question that was raised a decade ago when treatment programs were beginning: who should get priority for treatment?  Should those who are most likely to benefit get priority over those who are perhaps too sick to benefit from treatment?  These are difficult questions and there are certainly no easy answers.

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Global health webcasts

On July 15, 2010, in global health, resources, by Karen Grepin

For the rest of the summer, I have escaped from hot and steamy New York City to cool and airy rural Connecticut.  Despite my isolation, I have found that I have been able to remain relatively connected to the rest of the world thanks to a number of global health organizations that have made their recent events available via Webcast over the internet (and even available to those of us using DSL to access the internet):

A few weeks ago I watched much of the Women Deliver conference in D.C. from the comfort of my own living room.  Over the past few weeks, I’ve watched a number of excellent talks broadcast from the Center for Strategic and International Studies.  I tried to watch a great debate on HIV prevention at the World Bank – although technical glitches prevented the broadcasting of the debate.  Next week I plan to stream a great deal of the upcoming AIDS conference in Vienna streamed from the Kaiser Family Foundation.

All of these events have made being a part of the policy debates much easier for those of us who are not always able to travel to these events or are lucky enough to live in DC.  What is even better, many of these organizations have archived these talks making them available to you when you have time to watch them.  I personally this has been a great innovation in the global health policy space and look forward to more of such webcasts!

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“Scaling up” effective health services is high on the policy agendas of many countries and international agencies. The current concern has been driven by growing recognition both of the challenges of achieving the health-related Millennium Development Goals (MDGs) in many countries, and of the need to ensure that the increased resources for health channelled through disease-specific health initiatives are able generate health gain at scale. Effective and cost-effective interventions exist to address many of the major causes of disease burden in the developing world, but coverage of many of these services remains low. There is a substantial gap between what could be achieved and what is actually being achieved in terms of health improvement in low- and middle-income countries.

That is the lead paragraph from the editorial that accompanies a special supplement in BMC Health Services Research on scaling up health policies and health services in developing countries.  The supplement contains a series of interesting articles on the topic ranging from papers looking at antiretroviral treatment, cervical cancer screening, and malaria treatment.

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